Sections

August 11, 2016 -- Following the recent heated controversy over the scientific merits of flossing, DrBicuspid.com queried its informed readers to get their input about the issue. "Plaque control is considered the holy grail in dentistry," noted a dental instructor, while a dentist said flossing could become a blame game between dentists and patients.

An August 2 report by the Associated Press questioned the clinical evidence supporting the practice of flossing. The article examined 25 peer-reviewed studies on the effectiveness of flossing and found weak or unreliable evidence that flossing had long-term benefits.

The ADA and the American Academy of Periodontology fired back, maintaining that the use of "interdental cleaners," such as floss, are an "essential" part of periodontal care.

No harm, no foul?

Many dental professionals noted that flossing can't help but improve dental hygiene.

"Agitating the biofilm in the area of the proximal contact with floss in people with healthy biofilms is good and certainly does little or no harm," Paul Dirkes, DDS, of Atmore, AL, told DrBicuspid.com in an email.

But Dr. Dirkes said there are better alternatives to flossing.

"Other better options are water flossers with antimicrobials or using antimicrobial mouthwashes for 30 seconds, spit, and repeat," he wrote.

"I have never found flossing to reduce dental decay and stopped that message several years ago," Alleman wrote. "I also stopped telling patients to floss daily. Three times a week works just as great if you want to floss."

High rates of periodontal disease

Others pointed out that flossing would help fight the high rates of periodontal disease in the U.S., which includes 47.2% of American adults or 64.7 million people, according to a 2012 report by the U.S. Centers for Disease Control and Prevention.

"Plaque control is considered the holy grail in dentistry," wrote Lance Vernon, DMD, an instructor at the Case Western Reserve University School of Dental Medicine. "You would be hard-pressed to find a periodontist who would not argue that [minimally in those with periodontal disease] flossing and/or interproximal cleaning is an important measure to arrest/slow the progression of 'gum disease.' "

But Dr. Vernon acknowledged that many people do well without flossing.

"Are there some people who don't floss and are just fine? Yes," he wrote.

Better advice than flossing?

“Absence of evidence of effectiveness is not at all equivalent to evidence of absence of effectiveness.”

— Scott Tomar, DMD, DrPH

Some said that dentists can give their patients other recommendations that can produce more significant improvements to their dental health.

"I agree that floss is cheap and has minimal harms, but does advocacy for it detract from better health promotion messages (e.g., smoking cessation, which is a much more effective prevention message compared to flossing)?" noted Robert Weyant, DMD, a professor and the chair of the department of dental public health at the University of Pittsburgh.

Dr. Weyant also wondered if flossing could result in a blame game between dentists and patients.

"Does nonflossing among patients result in victim blaming by dentists when they feel that their patients aren't participating in appropriate health behaviors?" he stated.

Others pointed out that many people floss just because it feels better to get rid of the gunk that gets between their teeth after eating.

"I reminded my friends about their own subjective experiences with what they remove from their teeth when they floss, e.g., rotten, stinky food, and why would they want to have that stay in their mouths!" wrote Gail T. Brown, director of the New Hampshire Oral Health Coalition.

Absence of proof doesn't prove anything

Scott Tomar, DMD, DrPH.

Finally, Scott Tomar, DMD, DrPH, noted that peer-reviewed research into the benefits of flossing would make little sense financially or logically.

"Well-conducted randomized controlled trials would be very expensive, and I doubt the National Institute for Dental and Craniofacial Research and other major funders of biomedical research would be interested in spending the millions it would take to conduct such studies," Dr. Tomar wrote. "At the end of this long, difficult, expensive study, you have an unmasked trial at high risk for bias."

Dr. Tomar is a professor and the interim chair of the department of community dentistry and behavioral science at the University of Florida College of Dentistry in Gainesville, FL.

He also pointed out that a lack of proof doesn't prove anything.

"One principle worth bearing in mind is that absence of evidence of effectiveness is not at all equivalent to evidence of absence of effectiveness. It then comes down to weighing the probable risks and benefits. I intend to floss my teeth in a few minutes," Dr. Tomar concluded.

When I speak to groups of people including dentists, I often discuss that our primal ancestors over 2.5 million years of evolution rarely had tooth decay or gum disease, and they didn’t have floss or brushes as we do. We know they were mostly free of dental disease because their skeletal remains rarely demonstrated tooth decay or bone destruction from gum disease. These diseases generally evolved after agricultural farming and the predominance of processed grains and sugars in the diet. Gum disease and tooth decay are mainly results of what we put in our mouths, what we don’t put in our mouths, and the health of our gut microbiome. Flossing is important, and interdental cleaning with small brushes is more effective. I recommend cleaning the spaces between the teeth with a “Soft Pick” manufactured by GUM. However, living a primal lifestyle and eating a primal diet are more important. http://drdanenberg.com/

8/11/2016 8:52:00 PMMWDavisDDS

We won't be seeing any evidenced based research supporting the use of dental floss. Why? Well over 98% of dental research is funded by dental manufacturers. Less that 2% is basic dental science. Dental floss simply isn't a big money-maker. To quote Puff Daddy, "It's all about the Benjamins".

There's also scant research evidence on the health benefits of the personal hygiene of wiping one's backside after fecal defication. Unless toilet paper manufacturers fund such a study, we won't see the evidenced based support for this aspect of personal hygiene.

Thus, IMHO the rationale for not using dental floss based on a lack of supporting research evidence, employs the same logic as not wiping one's bottom post excrement discharge. In reality, both activities promote personal hygiene & remove potentially harmful bacteria from the host.

Michael W Davis, DDS Santa Fe, NM

8/12/2016 1:29:31 PMcoopersmith

The Associated Press, is correct when it published its recent article, “A big problem with flossing”. But it should have read “A Big Problem with Flossing Research.” I have done a great deal of research on the topic (see reference below) and there is little doubt in my mind that the science regarding flossing is flawed, inaccurate, biased, and often paid for by the big dental companies who manufacture and distribute dental floss. The direction and tone of this article seems to question whether it is important to floss or to clean between the teeth at all! Every dentist or hygienist that I have spoken with in over 40 years of active dental practice and teaching dentistry, has concluded that flossing in fact does work. We see the results every day and that when used properly, flossing removes or disrupts the germs between teeth where your toothbrush and mouthwash cannot reach. There is however good research and overwhelming evidence that these germs hiding between teeth contribute to cavities, gum disease, bad breath. They can even cause an increased risk of heart attacks, strokes, diabetes, even some cancers and other systemic diseases. The real problem with flossing is non- compliance. Few people floss and those who do floss, do it incorrectly. Flossing is technique sensitive and is inconvenient and difficult to learn or do. Many patients actually lie to their dentist or hygienist rather than receive a scolding for not flossing. There has to be a better way! That is why Nathalie Fiset RDH and I wrote an article in the July edition of the Journal of Oral Health “Gum Disease Starts Between the Teeth” and why we invented the PerioTwist which is “a one size fits all teeth” interdental cleaner. This device is so much easier to use than floss and will not only clean away the smelly germs between teeth, but can also medicate the area as well.

The Associated Press, is correct when it published its recent article, “A big problem with flossing”. But it should have read “A Big Problem with Flossing Research.” I have done a great deal of research on the topic (see reference below) and there is little doubt in my mind that the science regarding flossing is flawed, inaccurate, biased, and often paid for by the big dental companies who manufacture and distribute dental floss. The direction and tone of this article seems to question whether it is important to floss or to clean between the teeth at all! Every dentist or hygienist that I have spoken with in over 40 years of active dental practice and teaching dentistry, has concluded that flossing in fact does work. We see the results every day and that when used properly, flossing removes or disrupts the germs between teeth where your toothbrush and mouthwash cannot reach. There is however good research and overwhelming evidence that these germs hiding between teeth contribute to cavities, gum disease, bad breath. They can even cause an increased risk of heart attacks, strokes, diabetes, even some cancers and other systemic diseases. The real problem with flossing is non- compliance. Few people floss and those who do floss, do it incorrectly. Flossing is technique sensitive and is inconvenient and difficult to learn or do. Many patients actually lie to their dentist or hygienist rather than receive a scolding for not flossing. There has to be a better way! That is why Nathalie Fiset RDH and I wrote an article in the July edition of the Journal of Oral Health “Gum Disease Starts Between the Teeth” and why we invented the PerioTwist which is “a one size fits all teeth” interdental cleaner. This device is so much easier to use than floss and will not only clean away the smelly germs between teeth, but can also medicate the area as well.

When will we learn and advise that it is not the amount of plaque, but rather the composition of the plaque which is of concern. Flossing for those with benign plaque is not purposeful. And flossing for those with dysbiotic plaque is insufficient. For the latter, the evidence suggests Prevora is needed.